Dr. Samieh Sam Rizk, M.D., F.A.C.S
Manhattan Facial Plastic Surgery, P.L.L.C.
Director
1040 Park Avenue
New York, N.Y.10028
Name: ______Date of Birth: ______
Home Address: ______City: ______State: _____ Zip: ______
Home Phone: ______Age: ______Sex: M: ____ F: ____ Student? FT: ___ PT: ___
Cell Phone #: ______Email Address: ______
Marital Status: Married: ____ Single: ____ Widowed: ____ Divorced: ____
Employer’s Name: ______Work Phone #: ______
Employer’s Address: ______City: ______State: ___ Zip: ______
Social Security #: ____ - ____ - ____ Allergies To Medicine: ______
Primary Care Doctor (first and last name): ______Address: ______
Referring physician: ______Referral Phone #: ______
Name of Dermatologist: ______Phone#: ______
Parent / Guardian / Spouse Information
Name: ______Date of Birth: ______
Home Address: ______City: ______State: _____ Zip: ______
Home Phone #: ______Work #: ______SS #: ____ - ____ - ____
Primary Insurance
Name of Insurance: ______ID #: ______
Insured’s Name: ______Group #: ______
Insured’s Date of Birth: ______Insured’s SS#: ___ - ___ - ___
Employer’s Name: ______
Private Insurance Authorization for Assignment of Benefits/Information Release:
I, ______, understand that I am using my out-of-network benefits for services provided to me by Dr. Samieh Rizk and/or Park Avenue Facial Surgery, and for that reason I am primarily responsible for payment of services received. I authorize payments of medical benefits to Samieh Rizk, M.D., Manhattan Facial Plastic Surgery and Park Avenue Facial Surgery (each hereinafter a “Provider” and collectively, “Provider”) for any services furnished to me by the Provider(s). In exchange for not having to pay in advance for those services (or portion of services) that I am receiving which are, or may be covered by my out-of-network benefits, I agree to forward Provider(s) all checks and explanation of benefits that I receive from any of my insurance companies related to services that I have received from Provider(s) within five(5) days of receiving them, and further agree that if I fail to forward any such payment, I will be responsible for payment of the amount I receive from my insurance companies for such services, plus interest of 15% per year calculated on a daily basis at a rate of .416%, payable beginning five (5) days from the date that I received such payment from my insurance companies, plus all attorney’s fees and cost incurred by the Provider(s) for collection of such amount(s) from me.
______
Patient, Parent, Or Guardian Signature (if child is under 18 years old)Date
Health Questionnaire
Name: ______Date: ______
Reason for today’s visit: ______
- Have you suffered from? 7. Have you ever been hospitalized?
Yes No yes ___ no ___ please describe:
______
Heart Disease ______
High Blood Pressure ______
Heart Attack ______8. Have you ever had cosmetic surgery?
Emphysema ______Yes ___ no ___ please describe:
Asthma ______
Blood Disease ______
Kidney Disease ______
Glaucoma ______9. Have you ever had any other surgery?
Diabetes ______Yes ___ no ___ please describe:
Jaundice/Hepatitis ______
Cancer ______
Anemia ______
Easy Bruising ______10. Have you ever had any of the
Facial Trauma ______following habits? Yes ___ no ___
Dry Eyes ______smoking
Eating Disorder ______
Depression ______
Psychological Disorder ______Frequency ______
Elaborate as needed: ______Alcohol
______Frequency ______
______Recreational Drugs
2. Do you take? Frequency ______
St. John’s Wort ______11. Do you have any caps, crowns,
Aspirin ______bridges, or loose teeth?
Ginko ______
Vitamin E ______
3. Have you have ever taken? 12. Are you currently undergoing dental
Fen Fen ______work? ______
Accutaine ______
4. What medications do you use? 13. How did you hear of our office?
______Google ___ Ask.com
______Yahoo ___ Facebook
______AOL ___ Makemeheal.com
5. What medication are you allergic to? ___ Msn/Bing ___Other Website
___ Friend/Family ___ Physician
______
6. Do you have any other medical problems?
______
For Rhinoplasty and Nasal Patients Only
SAMIEH S. RIZK, M.D.
PATIENT’S NAME______
Please read and circle the condition that best describes you:
1. I have difficulty breathing through my nose.YesNo
2. I have a decreased flow of air through my nose. YesNo
3. I currently have nasal airway obstruction.YesNo
4. I breathe through my mouth.YesNo
5. I snore when I sleep. YesNo
6. I have recurrent headaches. YesNo
7. I have frequent nose bleeds.YesNo
8. I have frequent sinus infections.YesNo
9. I have had previous surgery on my noseYesNo
10. Please describe nasal surgery and give approximate date.
11. I have had an injury to my nose. YesNo
12. Please describe injury and give approximate date.
13. Please detail any additional information regarding your current nasal symptoms.
I have completed this form fully and completely, and certify that I am the patient or duly authorized general agent of the patient authorized to furnish the information requested. I authorize release of information to my insurance company.
SIGNATUREDATE